What is the clinical significance and management of a palpable Virchow's (left supraclavicular lymph) node?

Clinical Significance and Management of Virchow's Node

A palpable Virchow's node (left supraclavicular lymph node) is highly concerning for malignancy and requires prompt evaluation with imaging and biopsy rather than empiric antibiotics, especially when present for ≥2 weeks without obvious infectious cause. 1

Clinical Significance

• Virchow's node represents a metastatic deposit in the left supraclavicular lymph node, historically associated with abdominal and pelvic malignancies, but the pattern of primary tumors varies by geographic region 2, 3
• Risk factors suggesting malignancy in a supraclavicular node include: firm/hard consistency, fixation to adjacent tissues, size >1.5 cm, duration >2 weeks without fluctuation, and ulceration of overlying skin 1
• Left supraclavicular node metastases show a significant predilection for abdominal and pelvic primary tumors compared to right-sided nodes 2, 4
• In recent studies, the most common primary sites for Virchow's node metastasis are lung (22.5%), oral cavity (19.2%), breast (12.5%), and gallbladder (10%), with primary gut carcinomas constituting only 9% of cases 3
• Rare cases of hepatocellular carcinoma metastasizing to Virchow's node have been reported, likely via the hepatic node and thoracic duct 5

Diagnostic Approach

• A complete examination of all lymph node regions, including detailed examination of the head and neck, is necessary for patients with supraclavicular lymphadenopathy 1
• First-line imaging should include CT scan with contrast of the neck, chest, abdomen, and pelvis 1
• PET/CT is valuable for staging if malignancy is confirmed, identifying a primary tumor when metastatic disease is suspected, and guiding biopsy site selection 1
• Ultrasound can be useful for characterization and guided biopsy of supraclavicular lymphadenopathy 1
• Initial laboratory studies should include complete blood count with differential, comprehensive metabolic panel, and lactate dehydrogenase (LDH) 1
• Fine-needle aspiration biopsy (FNAB) is an excellent initial procedure for diagnosing the cause of an enlarged supraclavicular lymph node 2, 3

Management Approach

• Patients with supraclavicular lymphadenopathy without obvious infectious cause and present for ≥2 weeks should proceed directly to imaging and biopsy rather than receiving empiric antibiotics 1
• For confirmed malignancy, staging and management should follow specific cancer type guidelines 1
• In lung cancer staging, supraclavicular lymph node involvement is classified as N3 disease, which is a contraindication to maximal surgical cytoreduction 6
• In small cell lung cancer, the Veterans Administration Lung Study Group (VALSG) system defines ipsilateral supraclavicular lymph node involvement as limited-stage disease, while contralateral supraclavicular lymph node involvement is classified as extensive-stage disease 6
• For breast cancer, nodal irradiation remains indicated for patients with involved lymph nodes, including supraclavicular nodes 6
• In Merkel cell carcinoma, fine needle aspiration (FNA) is used to confirm metastatic disease in clinically positive lymph nodes, with lymph node dissection as the preferred treatment for palpable nodal metastases 6
• Long-term survival is possible even with Virchow's node metastasis when appropriate treatment is provided, as demonstrated in case reports of gastric cancer with appropriate chemotherapy and surgical management 7

Differential Diagnosis

• Metastatic malignancy (54.5% of diagnostic cases in one large series) 3
• Granulomatous lymphadenitis (25.9%) 3
• Acute suppurative lymphadenitis (9.5%) 3
• Reactive lymphadenitis (5.0%) 3
• Lymphoproliferative disorders (4.54%) 3

Clinical Pitfalls and Caveats

• Do not delay biopsy of a suspicious supraclavicular node by attempting empiric antibiotic treatment first 1
• Do not assume that all Virchow's node metastases originate from gastrointestinal primaries; the epidemiology has shifted in many regions 3, 4
• Remember that thoracic malignancies can involve either right or left supraclavicular nodes without showing a predilection for either side 4
• The significance of contralateral supraclavicular lymph node involvement in lung cancer staging remains controversial, with treatment usually determined individually based on the ability to include these regions in a safe radiotherapy port 6